99233 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99233 Current Procedural Terminology (CPT®) lecture reviews the
procedure code definition, progress note examples, RVU values and national distribution data. CPT® 99233 is the highest of the three
Healthcare Common Procedure Coding System (HCPCS)
inpatient hospital follow up codes. The low level CPT® 99231 and mid
level CPT® 99232 subsequent care codes are described elsewhere on The
Happy Hospitalist as part of a complete collection of CPT® lectures I have written previously . In addition, I have written a side-by-side comparison lecture detailing coding elements of 99232 vs 99233. I am a board certified internist with over ten years
of clinical experience in a community hospitalist program providing
physician services at a large regional hospital system. I have written
an extensive collection of evaluation and management (E/M) lectures
over the years to help other physicians and other non-physician
practitioners (nurse practitioners, physician assistants, clinical nurse
specialists and certified nurse midwives) understand the complex world
of hospital and clinic based evaluation and management coding requirements. These lectures were written several years ago, but the information remains highly relevant today.

These lectures and accompanying coding resources are used by myself to make sure I stay compliant with the rules and regulations of the Centers for Medicare
& Medicaid Services (CMS). All CPT® lectures I have written are organized in
one easy-to-find location on Pinterest. You don't need to be a Pinterest member to see all of my CPT®
procedure lectures. As you are learning to understand CPT® E/M coding,
always remember that it is your responsibility to make sure your documentation
supports your level of service you are submitting for reimbursement.
How much you write in the chart should not be used to determine your
level of service. What matters most are the details of your
documentation as defined by the rules discussed in this and other CPT®
lectures. The CMS E/M services guide says the care you provide must be
"reasonable and necessary". In addition, all progress notes must be
dated and have a legible signature or proof of signature attestation

CODE DISCUSSION

My interpretations detailed below are based on my review of the 1995 and
1997 E&M guidelines, the CMS E&M guide and the Marshfield
Clinic audit point system for medical decision making. Details of these files can be found in my hospitalist resource section at this link. The Marshfield Clinic point system is voluntary for Medicare
carriers but has become the standard compliance audit tool in many
parts of the country.Make sure to check with your own Medicare
carrier in your state to verify whether or not they use a different
standard than that for which I have presented here in my free
educational discussion. I recommend all readers obtain their own
up-to-date CPT® reference book as the definitive authority on CPT®
coding. The 2015 CPT® standard edition pictured below and to the right
can by found on Amazon by clicking on the picture file. CPT®
99233 is a hospital billing code and can be used by any qualified
healthcare practitioner to get paid for their inpatient hospital
subsequent care evaluations. The American Medical Association (AMA)
describes the 99233 CPT® procedure code as follows:

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

This code can be billedbased on time
under certain circumstances. I have detailed those discussions at the
link provided. Note however that documentation of time is not a required
component to stay compliant with CMS regulations. If this code is
billed without time as a consideration, CPT® 99233 documentation should be
based on the requirements stated in the 1995 or 1997
guidelines referenced above in my hospitalist resource section. The
three relevant components to a hospital follow up note are the:

History

Physical Exam

Medical Decision Making Complexity (MDM)

For all inpatient hospital subsequent care progress notes (99231, 99232, 99233), the highest documented two out of three
levels for history, physical and MDM will determine the correct level
of service. Compare this with the requirement for the highest three out of three
on initial hospital care encounters. I'll state it again. For hospital follow up progress notes, only the highest two out
of three components from history, physical and MDM are needed to determine the correct level of service provided. I have detailed below a discussion that explains the
absolute minimum requirements required to remain in compliance with CPT®
code 99233. Also remember that a face-to-face encounter is
required for all visits by CMS beneficiaries.

Detailed interval history: Requires 4 elements of the
history of present illness (HPI) OR documentation of the status of 3
chronic medical conditions AND 2 review of systems (ROS). No past
medical history or family history or social
history is required (PMFSH).

Detailed physical exam:

1995 E/M guidelines require an extended exam of the affected body area(s) and other symptomatic or related organ systems. These terms are poorly defined and I feel they are open to great variation of interpretation.
Note the wordage difference with body area vs organ systems. They are not
the same. A review of the acceptable body areas and organ
systems can be found in the CMS E&M reference guide on pages 31 and 32. I recommend instead to
consider using the 1997 guidelines that provide better clarity.

1997 E/M guidelines more clearly define the need for a physical exam that includes at least 6 areas with 2 bullets each, or 2+ areas with 12 total bullets.

High complexity medical decision making (MDM):
This is split into three components. The 2 out of the 3 highest levels
in MDM are used to determine the overall level of MDM. The level is
determined by a complex system of points and risk. What are the three
components of MDM and the minimum required level of points and risk as
defined by the Marshfield Clinic audit tool for high complexity MDM?

Diagnosis (4 points)

Data (4 points)

Risk (high) The table of risk can be found on page 37 of the CMS E&M reference guide.

The medical decision making point system is quite complex. I have a
detailed reference to it on my E/M pocket cards described below.
These cards help me understand everyday what type of care my documentation
supports. I carry these cards with me at all times and reference them
all day long. They help me understand what level of service my evaluation qualifies for.

CLINICAL EXAMPLES OF 99233

Here are my general thoughts on billing a 99233 follow up note: They almost always have some sort of new issue going on. That's a general rule I use when trying to decide whether or not to code this level, but that's by no means always the case. When billing a level three subsequent care note, I usually try and include medical decision making in my coding decision. As I said above, MDM is not required because only 2 out of three for history, physical and MDM must qualify for a level 3 99233. However, I feel, if I am doing a physical exam that warrants 12 bullet points, it's because they have an issue or are sick enough to qualify for the highest MDM category.

When I come upon a chart of a patient, I want to know if there are any new issues that have presented since my last evaluation. If the answer is yes, my documentation can usually support a level 3 progress note. Remember, the rules are not based on how much is written, but rather what is written. If the answer is no, I review the chart and medical conditions to decide whether the patient would qualify anyway. I think physicians universally underestimate risk as it applies to E/M coding. Many of our patients should be categorized as high risk and billed as such if other documentation supports the highest level of medically reasonable and necessary service. Listed below are some examples of 99233 hospital follow up notes in subjective, objective, assessment, plan (SOAP) format.

This note meets criteria for a level three CPT® 99233 progress note based on history and physical. Again, the highest two out out of three from history, physical and MDM documentation are used to define the level of service provided. The care must be medically reasonable and necessary. Some folks argue that MDM must be included as one of the three components for a high level E/M visit. The rules and guidelines we are asked to follow do not state that. Some may argue that 12 bullet points are not medically necessary without high complex medical decision making. As a practicing hospitalist of ten years, I would consider that assumption as inaccurate.

There are many patients that require intensive physical exam that may not have criteria for high complexity MDM. Documentation is vitally important to avoid any questions in an audit situation. If you feel an extensive physical exam is warranted everyday, document your reasoning why. That's what determines medically reasonable and necessary care. And always remember, when submitting payment to CMS, documentation must support at least one ICD (the problem) code from which to link the CPT® code to. I usually recommend documenting at least one problem in the note, unless the problem can be inferred elsewhere in the chart (such as in the orders as an indication for a test). Here's another example of a level 3 hospital progress note below:

Again, this progress note meets criteria for a level 3 based on history and physical exam once again. However, in this case, the status of three chronic medical conditions (which have relevance to the patient's condition) substitute for four elements of HPI. Documenting stable HTN, CAD and COPD with no changes planned is considered an appropriate substitute for 4 HPI. I would only consider using chronic conditions that have relevance to the patient's condition. Again, if there is any question about their relevance, document your thought process. The reason many physicians fail audits is not because they are committing willful fraud but rather because they commit omissions of documentation. They fail to explain their reasoning behind their decisions. Here is another level 3 progress note below:

In this progress note example a level three is achieved based on documentation bullets from the physical exam and medical decision making. Nothing is needed from the history component. Remember, two out of three for follow up hospital notes. I documented a 99233 in the medical decision making because I achieved 4 points in the data section with 2 points for discussing with Dr Smith and 2 points for personally reviewing the CXR. I also got high risk for drug therapy requiring intensive monitoring for toxicity. Coumadin is a drug that I follow for toxicity by drawing INR levels. I think Coumadin use in the hospital is high risk, under most circumstances, and I make sure my documentation supports my thought processes on why I consider it so. Remember, medical decision making guidelines also require a determination of the highest 2 out of 3 for data, diagnosis and risk. I received high complexity medical decision making based on data and risk. I had documentation of at least 12 bullets in 6 organ systems on physical exam. Therefore, this note meets criteria for a CPT® 99233. One does not need to write volumes of information to meet criteria for high complexity care. Here is another example:

This note meets a high level 99233 progress note based on physical exam and MDM again. Remember, 2 out of 3. History does not matter here. The physical exam achieves level three based on 12 bullets in at least 6 areas. The MDM is high complexity based on the diagnosis and risk components. I get 4 points for documenting 4 stable chronic medical conditions with AF, HTN, DM and CHF. I get high risk for documenting high risk drug management with warfarin. This is a level three progress note. The care and documentation is medically reasonable and necessary. These are hospitalist patients that I feel we under code every day because we fail to appreciate how complex they are and we fail to document work we are already doing to indicate complexity. Here's another 99233 example:

A) hypoxemia-new issue (Diagnosis-4 points for new problem with further workup planned)

P) get CXR, ABG

This is a high level subsequent care progress note based on physical exam and MDM. The physical exam has at least 12 bullet points in 6 areas. The MDM is high complexity based on diagnosis and risk. I get 4 points for addressing a new issue with further workup planned. In addition, I get high risk for drug therapy requiring intensive monitoring for toxicity. This is a level three progress note. Note once again how compact the note is. What is written matters. How much is written does not. Our guidelines tell us so. Here is another example of a 99233 progress note:

S) RLQ abdominal pain, sharp, started yesterday, constant (4 HPI)

no CP, no SOB (2 ROS)

O) nothing needed

INR 1.7 on Coumadin (high risk drug management)

A) hypoxemia-new (Diagnosis-4 points for new problem with further workup)

P) Check ABG, CXR

Level three is achieved using history and MDM. My history qualifies for a 99233 based on 4 HPI and 2 ROS. My MDM qualifies based on diagnosis and risk. I got 4 diagnosis points for a new problem with further workup planned. I got high risk for Coumadin management. Did you ever think you could write so little and still bill an appropriate 99223 based on the guidelines we have been given to follow? Here is another example using history and MDM:

4) hypoxemia-new (Diagnosis-4 points for new problem, more workup planned)

P) Discussed code status today. Patient wishes to be a DNR due to poor prognosis.(high risk for DNR discussion, order for DNR) Check CXR ( Data-1 point for radiology)

In this example, I substitute the status of three chronic medical conditions for the 4 HPI. The MDM is high complexity for risk and diagnosis. Discussing DNR and writing an order for such can qualify for high risk under the risk table guidelines. In addition, 4 points under diagnosis of a new medical condition with further workup planned meets high complexity care criteria. This is a level 3 progress note.
Here is one last example of a CPT 99233 based on history and MDM:

Discussed CXR findings with the radiologist (Data-1 point for discussing test with performing physician)

A) Patient on a PCA for back pain, no changes today (High risk for IV opiate management)

P) Nothing else needed

The history of 99223 compliant with 4 HPI and 2 ROS. The MDM is high complexity based on data and risk. The data has the required 4 points by 1 point for reviewing lab, 2 points for personally interpreting an EKG tracing and 1 point for discussing the CXR with the radiologist. In addition, the case is high risk based on IV opiate therapy, a high risk therapy based on the risk table guidelines we have been given for compliance.

DISTRIBUTION OF SUBSEQUENT CARE CODES

What is the distribution of CPT® 99231, 99232 and 99233 for internal medicine in the country? One Medicare contract carrier actuallytold us the answer in a January, 2013 pdf presentation (based on January 2011 through December 2011 data). Here is their analysis. I do not believe this data uniquely represents hospitalist data as opposed to internal medicine as a whole.

99231: about 8% of total inpatient subsequent care codes.

99232: about 62% of total inpatient subsequent care codes.

99233: about 30% of total inpatient subsequent care codes.

One additional resource described the ten year trend (2001-2010) of E/M coding trends. The OIG published a reportin May, 2012 titled Coding Trends of Medicare Evaluation and Management Services. As you can see, the proportion of 99231 vs 99232 vs 99223 has shifted to higher intensity of service codes over the last 10 years. This data is for all Medicare E/M charges in this code group and not limited to internal medicine as reviewed just above. As you can see, in 2010, 25% of subsequent inpatient hospital care codes were 99233, 59% were 99232 and 15% were 99231.

Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99233 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99233 had 22,285,570 allowed services in 2011 with allowed charges of $2,254,038,317.46 and payments of $1,789,718,423.32.

UPDATE: 2013 CMS Part B National Procedure Summary File

ALLOWED SERVICES: 21,680,023.2

ALLOWED CHARGES: $2,206,186,149.41

PAYMENT: $1,726,355,476.59

RVU VALUE

How much money does a CPT ® 99233 pay in 2015? That depends on what part of the
country you live in and what insurance company you are billing. All CPT® codes are paid in relative value units (RVUs). I have previously discussed the complex nature of RVUs. You can find that discussion here. For raw RVU values, a CPT® 99233 is worth 2.91 total RVUs. The work RVUs are 2.0. A complete list of RVU values
on common hospitalist E/M codes can be found here. What is the 99233 Medicare reimbursement? In my state, a CPT® 99233 pays about $99 in 2014. The 2015 RVU dollar value conversion rate is 35.8013.

You can
see many more of my E/M lectures here. I've tried to make this complex process as simple as possible to help others understand how important documentation is to stay compliant and to get appropriately paid for the work they are providing. It took me years of daily diligence and carrying my E/M pocket reference card around with me at all times to get comfortable with medical billing and coding.

please respond!!So, say I document enough for a level 3, but the patient issues are not truly complex? (COPD, improving, DM uncontrolled but not wildy so, nausea, etc) can I still bill level 3? also, even if I document 99232 and then the complexity is even less? I.E. DVT staying in house till INR theraputic? or chronic panreatitis, here for pain meds (like always), probably doesn't really have pancreatitis, planning on kicking them out tomorrow? no change in therapy? (already on oral meds?)still on IV? or Off IV? either way! please help!?

Question for you. If you write a social history, family history, review of systems with 10+ things in it, and a PMH of 2-3 problems, do you get points for each of those items, and does it automatically qualify you for a comprehensive history?

Actually, I am talking about the detailed history or comprehensive history for 99214, 99215 outpatient (sorry I may have posted here). In other words, if I program each note to have 10 ROS, Family Hx, Social Hx, PMH of at least 3 problems, along with a chief complaint with quality, duration, etc. is that automatically a "comprehensive" history?